Citation NR: 9607705
Decision Date: 03/22/96 Archive Date: 04/02/96
DOCKET NO. 93-06 439 ) DATE
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On appeal from the
Department of Veterans Affairs (VA) Regional Office in St.
Paul, Minnesota
THE ISSUES
1. Entitlement to service connection for a bipolar disorder,
for the purpose of accrued benefits.
2. Entitlement to service connection for the cause of the
veteran’s death.
REPRESENTATION
Appellant represented by: The American Legion
ATTORNEY FOR THE BOARD
W. Pope, Counsel
INTRODUCTION
The veteran had active service in the United States Navy from
November 1982 to October 1986.
An August 1991 rating decision by the VA Regional Office in
St. Paul, Minnesota (RO), denied entitlement to service
connection for a bipolar disorder. The veteran disagreed
with that decision; however, he died in January 1992. A
December 1992 rating decision denied entitlement to service
connection for the cause of the veteran’s death. The Board
remanded the case to the RO for further development in
February 1995. The appellant is the veteran’s father and has
indicated that he paid the veteran’s funeral expenses.
CONTENTIONS OF APPELLANT ON APPEAL
The appellant contends, in essence, that service connection
is warranted for a bipolar disorder and for the cause of the
veteran’s death, because the bipolar disorder was manifested
during the veteran’s service and contributed substantially to
his death by suicide.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1995), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the evidence of record
supports the appellant’s claims for service connection for
bipolar disorder, for accrued purposes, and for the cause of
the veteran's death.
FINDINGS OF FACT
1. Sufficient relevant evidence is present for an equitable
disposition of the present appeal.
2. An August 1991 rating decision denied entitlement to
service connection for a bipolar disorder. The veteran
disagreed with that decision.
3. The veteran’s death certificate states that he died of a
self-inflicted gunshot wound to the head on January 8, 1992.
4. A claim for accrued benefits for service connection for
bipolar disorder and a claim for the cause of the veteran’s
death were timely submitted by the appellant, the veteran’s
father, who paid the funeral expenses of the veteran.
5. There is a reasonable probability that the veteran’s
bipolar disorder originated during his active service.
6. There is a reasonable probability that the veteran’s
bipolar disorder significantly contributed to his death by
suicide.
CONCLUSIONS OF LAW
1. A bipolar disorder was incurred during the veteran’s
active peacetime service, for accrued purposes. 38 U.S.C.A.
§§ 1131, 5107, 5121 (West 1991 & Supp. 1995); 38 C.F.R.
§§ 3.303, 3.1000 (1995).
2. The veteran's service-connected bipolar disorder
contributed substantially or materially to the cause of his
death. 38 U.S.C.A. §§ 1310, 5107 (West 1991 & Supp. 1995);
38 C.F.R. § 3.312 (1995).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Initially, the Board notes that the veteran's claim is well-
grounded within the meaning of 38 U.S.C.A. § 5107, and that
all relevant facts have been properly developed for this
appeal.
Service connection may be granted for a disability which is
shown to have been incurred in or aggravated by active
service. 38 U.S.C.A. §§ 1131
Under the law, periodic monetary benefits to which an
individual was entitled at death under existing ratings or
decisions and due and unpaid for a period not to exceed one
year, shall, upon the death of such individual be paid to the
living person first listed below: the veteran's spouse, the
veteran's children (in equal shares), the veteran's dependent
parents (in equal shares). In all other cases, only so much
of the accrued benefit may be paid as may be necessary to
reimburse the peerson who bore the expense of last illness or
burial 38 U.S.C.A. § 5121; 38 C.F.R. § 3.1000.
To establish service connection for the cause of the
veteran's death, the evidence must show that disability
incurred in or aggravated by service either caused or
contributed substantially or materially to cause death. For
a service-connected disability to be the cause of death, it
must singly or with some other condition be the immediate or
underlying cause, or be etiologically related. For a
service-connected disability to constitute a contributory
cause, it is not sufficient to show that it casually shared
in producing death, but rather it must be shown that there
was a causal connection. 38 U.S.C.A. § 1310; 38 C.F.R.
§ 3.312.
I. Background
The veteran’s service medical records disclose that, during
an August 1982 preenlistment examination, he denied prior
treatment for a mental condition. He was hospitalized for
psychiatric evaluation in July 1983, following a suicidal
gesture, and reported that he had been depressed because he
feared prosecution for withholding information about
psychiatric treatment prior to service. He indicated that
his pre-service depression had been resolved through
conservative measures, without the need for hospitalization.
He admitted a seven week history of depression and of
harboring suicidal thoughts following his graduation from
submarine school. It was determined that his personality
structure did not qualify him for submarine duty, but that he
met the medical standards for retention. The diagnosis was
mixed personality disorder, manifested by emotional lability,
periods of unmotivated sadness, suicidal gesture with
ideation, presently controlled, and easy suggestibility. He
was discharged to duty on the third hospital day.
The veteran was hospitalized upon referral in January 1985
with diagnoses of positive suicide risk at present, and rule
out paranoia vs. mixed personality disorder with paranoid
features. He was initially withdrawn and paranoid upon
admission, and transferred to a locked ward after a suicide
note was found. He improved after four days, and testing
revealed no evidence of psychotic features or a major
affective disorder. An administrative separation was
strongly recommended based on the severity of his personality
disorder. The diagnoses were schizotypal personality
disorder, recompensated, stable, and borderline intellectual
functioning. He was discharged on the twelfth hospital day.
An examination report by a clinical psychologist in April
1985 noted that the veteran had been medically recommended
for administrative separation in January 1985, but had been
retained by the base command and required to attend group
therapy and stress management classes at the mental health
unit. A mental status examination revealed that he was fully
oriented and alert, with a full range of affect congruent
with a euphoric mood. His content of thought was focused
primarily on a desire to be retained in the Navy. He was
assessed as not suicidal or homicidal. His judgment was
considered fair, and his insight limited by concreteness in
thinking. The diagnoses were borderline intellectual
functioning and schizotypal personality disorder,
recompensated, stable. The examiner deferred a decision
regarding retention to the base command.
The veteran’s October 1986 report of separation examination
noted that a psychiatric examination had not been performed.
VA medical records confirm that the veteran was hospitalized
in January 1988 with complaints including an inability to
sleep and racing thoughts. He reported a special power of
being able to see into the future, which scared him, and
noted that he had had the same experience when he had
attempted suicide in service. His affect was irritable and
labile from pleasant to loud and angry rapidly, from neutral
to teary rapidly with quick recovery. His speech was
slightly pressured and at times slightly tangential with
occasional flight of ideas. His thought content revealed
racing thoughts and “visions.” It was not determined that he
experienced auditory hallucinations. He did not exhibit
violent behavior, and denied suicidal ideation, throughout
his stay. He refused to begin medications (Lithium therapy),
because he denied a mental illness. The diagnosis was
bipolar affective disorder, Type II. He was believed to be
competent, not a danger to himself or others, and was
discharged on the fourth hospital day.
The veteran was readmitted to VA medical facilities a number
of times for psychiatric treatment in April 1988, usually
leaving against medical advice (AMA). He reported a six to
eight week history of sleep disturbance, and was noted to be
very suspicious and disorganized. He agreed to Lithium
therapy when encouraged during a family conference, but
immediately left the hospital AMA after the conference. The
consistent diagnosis was bipolar disorder.
The veteran continued to receive psychiatric treatment from
VA, although avoiding recommended medication therapy, through
May 1991. During hospitalization in April 1991 it was
believed that “unlike many other hospitalizations in the
past” it appeared that the veteran had formed a therapeutic
alliance with his treatment team and, therefore, had a better
chance of continuing compliance with treatment and follow-up.
When seen in early May 1991 he appeared tense, depressed and
worried. It was noted that he lived with his parents.
Several weeks later he appeared relaxed, spontaneous and
mildly euphoric. He had lost his job because he was “too
talkative”, as observed by a supervisor. He admitted
noncompliance with his medication, and acknowledged a
probable connection.
The veteran’s claim for entitlement to service connection for
a bipolar disorder was received in May 1991. As noted above,
that claim was denied in August 1991. A notice of
disagreement was received, and a statement of the case
issued, in November 1991. A statement, signed by the veteran
on December 30, 1991, indicated a desire to withdraw the
notice of disagreement and terminate the appeal process.
The veteran’s certificate of death reveals that he died of a
self-inflicted gunshot wound to the head on January 8, 1992,
at the age of 29. Chronic bipolar disorder was listed as a
significant condition contributing to death but not resulting
in the underlying cause of death. An autopsy had been
performed. The manner of death was listed as suicide.
II. Analysis
Regarding accrued benefits and whether the veteran’s claim
for service connection for bipolar disorder was pending at
the time of his death, the Board notes the appellant’s
assertion that the veteran was not of sound mind when he
submitted a withdrawal of the claim. Although the appellant
is not qualified to provide a medical determination of mental
“soundness”, he was able to observe the veteran’s behavior on
a regular basis, since the veteran lived in his home. In
addition, one can not ignore the proximity of the veteran’s
last communication with VA and his death, in a manner which
suggests “unsound” reasoning. Accordingly, with reasonable
doubt resolved in the appellant’s favor, the Board finds that
the veteran’s claim of service connection for a bipolar
disorder was pending at the time of his death.
Upon review, the Board notes striking similarities between
the symptoms manifested by the veteran during service,
beginning in July 1983, and in January 1988 when bipolar
disorder was diagnosed. The most striking psychiatric
evidence throughout the record concerns suicide; beginning
with a suicide gesture in July 1983, continuing with
references to suicidal ideation during and after service, and
ending with the veteran’s death by suicide in January 1992.
The Board recognizes that the mental disorders diagnosed
during the veteran’s service did not include a psychotic
disorder, and that his bipolar disorder was not confirmed by
diagnosis until approximately 14 months after his separation
from service. However, in view of foregoing record of
psychiatric treatment and the severity of the psychosis at
time of his initial post-service hospitalization, it is the
Board’s judgment that the evidence is sufficient to support
the conclusion that there is a reasonable probability that
the veteran’s bipolar disorder originated during his active
service. Accordingly, it follows that service connection for
a bipolar disorder, for accrued purposes, is warranted.
As the certificate of death clearly implies, the veteran’s
chronic bipolar disorder was a significant condition
contributing to death. In view of the continuing references
to suicide and suicidal ideation during the veteran’s
exacerbated episodes of bipolar disorder, it is also the
Board’s judgment that the evidence is sufficient to support
the conclusion that the veteran’s bipolar disorder
contributed significantly to his death by suicide.
Accordingly, the Board finds that entitlement to service
connection the cause of the veteran’s death is warranted.
38 U.S.C.A. § 1310; 38 C.F.R. § 3.312.
Finally, the Board wishes to point out that the benefit of
the doubt has been resolved in the appellant’s favor. 38
U.S.C.A. § 5107.
ORDER
Service connection for bipolar disorder, for accrued
purposes, and for the cause of the veteran’s death is
granted.
JAMES R. ANTHONY
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1995), a decision of the Board of Veterans'
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans' Appeals.
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